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- Attachment B to REQUEST FOR PROPOSALS-Forms <br /> General Contractor/Construction Manager Services for <br /> Water Pollution Control Facility Expansion-Phase C <br /> FORM 2 <br /> SAFETY & HEALTH QUALIFICATIONS STATEMENT <br /> • Please do not leave blanks on any item except lists; use `n/a' if a field does not <br /> apply. <br /> • You may neatly handwrite the information. We are more concerned about correct <br /> complete information than how it looks. <br /> Legal Name of your Company: <br /> Street Address: City: State: Zip: <br /> Mailing Address: City: State: Zip: <br /> Phone: Fax E-Mail Address: <br /> Is this address the: ❑ Main Office ❑ Regional Office ❑ Branch Office <br /> ❑ Other <br /> 1. Please list the trade(s) in which your company performs work: <br /> CSI Division No. Description <br /> 2. For work in Washington State (Intrastate), please list your Company's Workers' <br /> Compensation Experience Modification Rate (Experience Factor)for the most <br /> recent three years, using the Washington State Department of Labor and <br /> Industries ratings: http://www.lni.wa.gov/ORLI/LoGon.asp. <br /> Year Rate Year Rate Year Rate <br /> 2011 2010 2009 <br /> City of Everett Page B2 April 16, 2012 <br /> Water Pollution Control Facility Expansion-Phase C42 <br />